Electronic medical records: Questions journalists should ask

It’s rare for doctors to turn out en masse for a public protest. But that’s what happened at “Doccupy” in Contra Costa County, California in 2012. A group of safety net physicians testified before county supervisors — in what they only half-jokingly called “Doccupy” — that the cumbersome move to electronic health records (EHRs) had taken an enormous toll on patient care. The doctors saw half their usual number of patients. As a result, they told supervisors, one in ten patients left the emergency room without being seen and wait times ballooned from one to four hours — with one person waiting 40 hours for a hospital bed.

This protest came on the heels of a letter from a group of county jail nurses asserting concerns about the same electronic records system. A subsequent New York Times article pointed out additional productivity and patient safety issues raised about electronic medical records at other locations, even from health care establishments as impressive as the Mayo Clinic.

It might be tempting to think of these stories as an aberrant blip. But surveys show Doccupy may have just been the first sign of trouble with electronic health records nationwide.

The average length of time that survey respondents had been using their EHRs was more than three years at the time of completing the EHR satisfaction survey.

Satisfaction and usability ratings are dropping. This holds true regardless of practice size, specialty type and across multiple vendors.

In 2012, 39% of clinicians would not recommend their EHR to a colleague.

Dissatisfaction with ease of use was reported among 37% of respondents in 2012, compared with 23% in 2010.

And 32% of respondents had not returned to normal productivity levels in 2012 compared to 20% in 2010.

For nearly a decade, medical technocrats have touted the promise of EHRs to revolutionize health care (the Office of the National Coordinator for Health Information Technology was created under President George W. Bush’s Administration). The Affordable Care Act has hastened their implementation. The idea is that they’ll reduce paperwork and administrative costs. But as more providers jump onboard, the negative impacts seem to be growing.

EHRs are supposed to streamline health care and reduce errors, right? Unfortunately, not necessarily. Kaiser Health News reported on a JAMA-published study that found “nearly 30 percent of doctors responding to a survey say they have failed to notice important test results because of the deluge of information available with electronic records.”

Imagine if we went back in time, when EHRs were initially proposed. What if sponsors said at the time that these systems would decrease productivity for one-third of doctors permanently, and make one third of doctors more error-prone? Well, it seems like the research may have been missing in all the miracle claims. “

‘The technology is being pushed, with no good scientific basis,’ says Dr. Scot M. Silverstein, a health IT expert at Drexel University quoted by the New York Times. He reports on medical records problems on the blog Health Care Renewal. He says testing these systems on patients without their consent “raises ethical questions.”

And then there’s the cost. The Contra Costa Epic EHR system cost $45 million dollars. Trade publication FierceHealthITnotes,

One Health Affairsstudy put the cost for an average five-physician practice at $162,000 for implementation, plus $85,500 in maintenance expenses during the first year alone. Meanwhile, clinical and nonclinical staff spent 134 hours per person, on average, to prepare for use of the record system in clinical encounters, according to the study. The cost for a physician practice sounds like a bargain when compared to a large, complex system. For Detroit’s Henry Ford Health System, the price tag was a whopping $356 million, an outlay it said was a major factor in a 15 percent decrease in net income in 2012.

Consider the health care efficiency math: That $162,000, plus another $85,000 in indirect costs, could almost pay for an additional full-time primary care doctor. Plus, the 134 hours devoted to the EHR implementation represents four and a half weeks of full time work for five physicians — six months of clinic time lost– all in addition to the price tag of the system. The $45 million for Epic in Contra Costa County would pay an annual $200,000 salary for 225 primary care or pediatric doctors. The $356 million price tag in Detroit clocks in at 1,780 full-time primary care and pediatric doctors for a year — and there are only 1,003 total doctors of all specialties practicing in Detroit!

These are the kind of hits our safety net systems can’t afford.

So what does this mean for you and your community? Here are some questions journalists can ask:

1. How long is the wait time for a primary care appointment in your area? You might want to call around and get some numbers.

2. How much has access been decreased (by number of slots available) for an EHR rollout? For how long? What is the cost of that, in human terms? Has it returned to normal? Will it ever?

3. Follow the money. How much money is being spent on the systems in your area? By whom? The taxpayers? Which hospitals or practices have tapped into federal funding for their systems?

4. How were contracts for these systems decided?

5. See if you can find a local provider who’s willing to show you just how their system works – is it as “burdensome” as these articles describe? Are test results buried in a pile of “information overload”?

6. Will there be an attempt to intimidate you if you write about it? Do patients have a right to know what their system is like, or even how much the system commands of their doctor’s time?

7. Are there obvious or predictable holes in the EHR? Are deaths recorded? By whom? Do transgender people have a way to fit into the allowable checkboxes?

8. What was the alternative? Would rolling these systems out more slowly, and with more oversight and review, lessened their negative impact? Would they be better tested and designed? Would there be fewer errors?

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LeoHolmMD

Yep. Another broken promise from technology.
I assure you, medical errors are up, costs are up, efficiency and access are down.
It’s not that EHRs are a bad idea. It just needed to be done correctly with some programmers who knew what they were doing, and some real physician input. It also did not need to be rushed, as the HHS continues to do, despite being aware of the harm they are causing, for nothing more than political gain.

buzzkillerjsmith

A transgender box ?! I didn’t see that one coming.

One a more serious note, Dr. G. is beating a horse that has already been turned into glue and used to paste I love you hearts onto the wall of second grade classrooms all over this beautiful country.

Everyone at this blog knows that EHRs are crap. Every single person.

FEDUP MD

Actually, my EHR insists everyone has a mother and father. No way to put in stepfamilies, and absolutely no way to put in gay couples where there are 2 moms or 2 dads (which I have quite a few of)! One lesbian couple had fun with the form by listing dad’s occupation as “anonymous sperm donor.”

LeoHolmMD

The public may not. Although a tremendous amount of time is wasted bashing the Obamacare site rollout, EHRs continue to cause major problems that directly affect patient care. Where is the press?

LeoHolmMD

The things you mention were available on paper, and were actually more accessible in the paper chart. All those redundant notes? Medicare/payers demand that behavior. Most physicians would be glad to change that tomorrow.

1SB

So the ER in NYC can access the paper EKG performed in Calif? Nope.

The MRI that was done 10 years ago that it now in storage is also not accessible.

LeoHolmMD

The situation you quote has not changed any. Interoperability has not happened. So unless CA and NY have a network no one knows about, the EHR still does not communicate. And the MRI that was in storage, is still in storage. Even when interoperability is in place, your own physician sitting in front of you today is the one having the problems accessing your record.

southerndoc1

Hopefully ERs in NYC are not making important and urgent clinical decisions based on EKGs in CA, accessible or not.